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Pulmonary Embolism

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  • Two theories to the origin of fat emboli: 1) Mechanical theory suggests that fat is released from the marrow of injured bone. It is driven out by an increase in intramedullary pressure and enters the circulation through draining veins traveling to pulmonary capillaries, where it lodges. The fat droplets traverse the capillary bed to enter the systemic circulation, where they embolize to other organs such as the brain
  • -S.J. is considered overweight which is a risk factor for PE. -Women of childbearing age who take estrogen based oral contraceptives are at increased risks for venous thromboembolic disease which can lead to pulmonary embolus.-SJ is being hospitalized following surgery. Anyone who has had surgery within the last 3 months are at increased risk for PE. Many patients who undergo surgery are immbolized and are at increased risk for PE.
  • -Patients with a DVT in the calf will often have a warm and swollen calf. The affected calf may also be larger in size than the unaffected calf. -An indication of establish thrombosis in the leg veins is a positive Homan’s sign in which there is presence of calf pain during sharp dorsiflex of the foot. This is a sign of the presence of DVT which in turn can lead to PE.-Patient’s diagnosed with DVT are put on Heparin which is an anticoagulant.
  • -Sudden onset of dyspnea, sharp chest pain, restlessness and anxiety are signs and symptoms of pulmonary embolism.- Patient’s increase in blood pressure may be due to pain and anxiety. She exhibits tachypnea, tachycardia and she is slightly febrile which are all signs and symptoms of PE.
  • -After 24 hours x-ray examination may reveal small infiltrates secondary to atelectasis that result in from the decrease in surfactant. If pulmoary infarction is present, infiltrates and pleural effusions may be seen within 12-36 hours.-Hypocarbia (PaCO2 7.45) usually are present in PE. A normal PaO2 still may not rule out the presence of a pulmonary embolism.
  • -Pulmonary ventilation perfusion scan is used to detect abnormalities of ventilation or perfusion. If the scan shows a mismatch of ventilation and perfusion (ie: pattern of normal ventilation and decreased perfusion), vascular obstruction is suggested.-PT and PTT are used to monitor the patient’s anticoagulant status. Nursing care includes assessing for the complications of anticoagulant therapy. The angiogram ordered for S.J. was then postponed pending the reversal of the anticoagulation.
  • -These are all indications of PE.- S.J.’s SaO2 which was being monitored by pulsoximeter drops to 81% which is indicative of hypoxemia.
  • -Pulmonary angiogram is the definitive test for diagnosis of PE.
  • Since inferior vena cava filters are the most frequently used for the interruption. I will focus on these.
  • Performing the angiography also helps to see the anatomy of the Inferior vena cava and be aware of any abnormal anatomical findingsWhen thrombus extends up to the renal veins, suprarenal placement may be needed. Suprarenal placement has a potential complication of renal impairment due to occlusion.4. The advantage of retrievable filters is that they can be removed with a second surgery, which is particularly useful for a patient that has only a short-term contraindication to anticoagulation, or they can be permanently left in a patient that develops the need for a permanent cava interruption.
  • Indications – 1. Sometimes initial anticoagulant therapy does not work because anticoagulation is not yet at the therapeutic range and the dosage needs to be increased.3. After the embolism is removed, the IVC is placed to prevent future reccurences of PE.

Pulmonary Embolism Pulmonary Embolism Presentation Transcript

  • Pulmonary Embolism
    1. Interpret the pathophysiology of the topic into fundamental concepts.
    2. Identify pertinent nursing assessments.
    3. Discuss diagnostic testing associated with the case.
    4. Illustrate case study topic with clinical examples.
    5. Identify appropriate nursing diagnoses in priority order.
  • Sandra James is a 32 y. o. female with a history of varicose veins. She is a 5'2" and 150 lbs. Ms. James has two children ages 6 and 4. Her current method of birth control is oral contraceptives.
     
    She is currently hospitalized following excision of internal and external hemorrhoids. All other history is insignificant.
     
    Ms. James’postoperative course is uneventful until the second day when she complains of pain in her left calf. On examination you find the calf swollen and warm to the touch
    L R. Homanssign is positive
     
    A Patient Arrives
  • You inform the primary physician and a doppler flow study is performed. The results reveal a left popliteal deep vein thrombosis.
     
    Ms. James is placed on bed rest and anticoagulation therapy via a continuous heparin infusion. She does well on heparin for 2 days after which she begins to c/o shortness of breath and left anteior chest pain that worsens with deep inspiration. She is restless and afraid and says, “Am I going to die?”
  • Physical assessment reveals the following:
     
    BP 160/88
    HR 120
    Resp 34 and labored
    Temp 99EF
  • A stat chest x-ray showed left lower lobe atelectasis. Ms. James is started on O2 via nasal cannula at 4 liters/min and an arterial blood gas is drawn. The following results are obtained:
     
    PH 7.52 ↑
    PaCO228 ↑
    PaO2131
    SaO299%
  • A ventilation perfusion scan performed that afternoon reveals perfusion defects of the anterior and posterior segments of the left upper lobe. Ventilation is normal, and a pulmonary embolus (PE) is suspected. Ms. James is scheduled for a pulmonary angiogram the next morning.
     
    On the morning of the scheduled angiogram, Ms. James PT and PTT are as follows:
     
    PT 16.7 sec. PTT 46.9 sec.
    Control 1.7 sec. Control 25.3 sec.
    INR
  • The angiogram is postponed pending reversal of the anticoagulation.
     
    Several hours later, Ms. James exhibits tachycardia, diaphoresis, and cyanosis. Her SaO2, which is being monitored by pulse oximeter, drops to 81%. She is placed on a 100%nonrebreathing mask. An ABG is drawn after 30 min., and the results are as follows:
     
    pH 7.48
    PaCO 30
    PaO2 45
    SaO2 81%
  • Ms. James is intubated and placed on a volume ventilator. A moderate amount of blood-tinged secretions are suctioned from her endotracheal tube. A pulmonary angiogram done that day reveals emboli in the left upper lobe lingular and right main pulmonary arteries. Bilateral iliac vein Greenfield filters are placed under fluoroscopy and anticoagulation therapy is resumed. Once the prothrombin times are in the therapeutic range. Coumadin is started. Ms. James is extubated 24 hr after the filters are placed and the heparin is discontinued after 72 hr. She makes steady progress and is discharged on Coumadin therapy several days later.
  • Pathophysiology of Pulmonary Embolism
  • There are the four major types of pulmonary emboli?
    Fat Emboli
    Air Emboli
    Amniotic Fluid Emboli
    Thrombus (Clot Emboli)
  • Long term immobility
    Oral contraceptive use
    Estrogen therapy
    Smoking
    Hypercoagulability
    Obesity
    Surgery
    Heart failure
    Chronic Atrial fibrillation
    Autoimmune hemolytic anemia (sickle cell)
    Long bone fractures
    Advanced age
    Major Risk Factors for PE
  • Fat Embolism: circulatory condition characterized by a plug of fat blocking an artery. The plug enters the circulatory system after the fracture of a long bone or traumatic injury to adipose tissue or to a fatty liver. Fat emboli are the result of the release of free fatty acids, causing a toxic vasculitis, followed by thrombosis, and obstruction of small pulmonary arteries by fat. Usually occurs within 12-36hrs after an injury.
    Risk Factors
    • multiple fractures
    • Males
    • Patients 10 – 39 years old
    • Trauma to adipose tissue or liver
    • Burns
    • Osteomyelitis
    • Sickle cell crisis
  • 2. Air Embolism: the abnormal presence of air in the CV system resulting in obstruction of blood flow. May occur if large quantity of air is inadvertently introduced by injection (as during IV therapy or surgery) or by trauma (puncture wound)
    Risk Factors
    • Any surgical procedures that can lead to infusion of air
    • Creation of a pressure gradient of air entry (ex. Lumbar punctures, peripheral IVs, central venous catheter, etc.)
    • Positive pressure ventilation (during mechanical ventilation or scuba diving)
    • Blunt & penetrating trauma to the chest, abdomen, neck, or face can lead to entry of air
    Wittenberg, A.G. (2006). Venous air embolism. Retrieved February 6, 2008, from eMedicine WebMD on the World Wide Web:http://emedicine.medscape.com/article/761367-overview
  • 3. Amniotic Fluid Emboli (AFE): occurs when amniotic fluid is drawn into the maternal circulation and carried to the woman’s lungs. Fetal particulate matter (skin cells, vernix, hair, and meconium) in the fluid obstructs pulmonary vessels. Failure of the right ventricle occurs early and can lead to hypoxemia. Left ventricle failure follows
    Risk Factors
    • medical induction of labor,
    • multiparity,
    • cesarean section or operative vaginal delivery,
    • abruption,
    • placenta previa, and
    • cervical laceration or uterine rupture
  • 4. Thrombus: a condition in which a blood vessel is obstructed by a thrombus carried in the bloodstream from its site of formation. The area supplied by an obstructed artery may tingle & become cold, numb, and cyanotic. Thrombi can result from blood stasis, alterations in clotting factors, and injury to vessel walls.
    Risk Factors
    Immobility
    A-fib, heart failure/MI, rheumatic heart disease
    Prolonged surgery (longer than 30min)
    Pregnancy
    Postpartum period
    Trauma
    Mechanical ventilation
    Obesity
    Age > 55y/o
  • What are the signs and symptoms of Pulmonary Embolism?
    Resources
    • http://www.mayoclinic.com/health/pulmonary-embolism/DS00429/DSECTION=symptoms
    • http://www.apsfa.org/pesymptoms.htm (NIH Publication No. 05-5684 March 2005)
  • Signs Vary Based On:
    Lung Involvement,
    Clot Size,
    Degree of:
    Heart Disease
    Lung Disease
    http://dvt-livingwithdvt.blogspot.com/2008/03/dvt-and-pulmonary-embolism.html
    http://improvedbreathing.com/
    http://www.libsearthwatch.com/?p=178
  • Shortness of Breath
    When Active
    or
    At Rest
  • Unexplained Pain in Chest
    Varies from sharp to dull, and no set location, however will increase with exertion but will NOT subside with rest
    http://www.flickr.com/photos/partymonstrrrr/2868149940/
  • BEWARE:The next slide has a nasty picture:Close your eyes if you don’t like mucus!
    http://www.mcglinch.com/blog/2007/10/beware-all-ye-who-enter.html
  • Bloody Cough
  • Tachycardia
    http://www.healthopedia.com/pictures/electrocardiogram-of-ventricular-tachycardia.html
  • Wheezing
    Leg swelling
    Clammy or bluish-colored skin
    Excessive diaphoresis (sweating )
    Anxiety , Feelings of dread
    Weak pulse
    Lightheadedness or fainting (syncope)
    Fever
    Other Possible Signs
  • The three classic signs of dyspnea, chest pain, and bloody cough (hemoptysis) only occur in 20% of patients
    The most common manifestations are anxiety and sudden onset of unexplained dyspnea, tachypnea, or tachycardia
    Another common finding is moderate hypoxemia with a low PaCO2
    Crackles (Rales) and a sudden change in mental status as a result of hypoxemia are other manifestations
    Review / FYI In Depth
  • Massive emboli may result in sudden collapse of patient with shock, pallor, severe dyspnea, hypoxemia and crushing chest pain, although some with massive PE do not experience pain.  The pulse is rapid and weak, low BP, and ECG shows right ventricular strain.  When there is rapid obstruction of 50% or more of pulmonary vascular beds, corpulmonale may result since the right ventricle can't pump blood to the lungs.
    Medium sized emboli often cause pleuritic chest pain, dyspnea, slight fever, a productive cough with blood streaked sputum, and tachycardia and a pleural friction rub may be found upon examination.
    Small emboli usually go undetected or produce vague, transient symptoms.  Repeated small emboli gradually cause a reduction in the capillary bed and eventually pulmonary hypertension.
    Review / FYI in Depth
  • Nursing Assessments
  • Nursing Assessment for Pulmonary Embolism: Risk Factors
    • Immobilization
    • Surgery within the last 3 months
    • Stroke
    • History of DVT
    • Malignancy
    • Obesity
    • Smoking
    • Hypertension
    • Oral Contraceptives
  • Sudden onset of dyspnea or tachypnea
    Tachycardia
    Sharp chest pain
    Restlessness and anxiety
    Nonproductive cough or hemoptysis
    Palpitations
    Nausea
    Syncope
    Mild to moderate hypoexmia with a low PaCO2
    Nursing Assessment: Signs and Symptoms of Pulmonary Embolism
  • Crackles
    Fever
    Decreased chest wall excursion
    Diaphoresis
    Edema
    Cyanosis
    Nursing Assessment: Signs and symptoms continued
  • History: 32 y.o. female with a history of varicose veins.
    5’2 and 150 lbs (BMI: 27.4; Overweight is 25-29.9)
    Patient is on oral contraceptives
    S.J. is being hospitalized following surgery for excision of internal and external hemorrhoids.
    Nursing Assessment for S.J.: Risk Factors
  • Left calf pain; swollen and warm to touch (L>R)
    Positive Homan’s Sign.
    Doppler Flow study a left popliteal DVT.
    Patient on Heparin.
    Nursing Assessment Data: S.J.
  • Patient complains of shortness of breath and left anterior chest pain (worsens with deep inspiration)
    Patient is restless and afraid.
    Vital Signs:
    BP: 160/88
    HR: 120
    RR: 34 and labored
    Temp: 99° F
    Nursing Assessment Continued
  • X-ray: left lower lobe atelectasis
    ABG results:
    PH: 7.52 (high)
    PaCO2: 28 (low)
    PaO2: 131
    SaO2: 99%
    Nursing Assessment Continued
  • Ventilation perfusion scan reveals perfusion defects of the anterior and posterior segments of the left upper lobe. Ventilation is normal.
    PT: 16.7 sec (normal: 12-15 seconds)
    PTT: 46.9 sec (normal: 30-45 seconds)
    Nursing Assessment Continued
  • S.J. exhibits tachycardia, diaphoresis, and cyanosis.
    Another ABG drawn 30 minutes later:
    PH: 7.48 (high)
    PaCO2: 30
    PaO2: 45
    SaO2: 81%
    Nursing Assessment: several hours later
  • S.J. is intubated, moderate amount of blood tinged secretions are suctioned.
    Pulmonary angiogram reveals emboli in the left upper lobe lingular and right main pulmonary arteries.
    Nursing Assessment Continued
  • Diagnostic Testing for Pulmonary Embolism
    • Spiral CT scan
    • Ventilation-Perfusion scan
    • Pulmonary angiography
    • Capnogram
    • D-Dimer and Fibrin Degradation
    • Cardiac Markers
    • Venous Ultrasound
    • Phosphorus Serum
    • ABG
    • Not diagnostic but help in diagnosing: Chest X-ray, history and physical examination, CBC count with WBC differential
  • Spiral CT scan
    • Spiral CT is similar to the regular CT, but the spiral CT actually spirals around the body giving a 3D image.
    • 1st line test for Pulmonary Embolism
    • “The spiral CT scan is able to continuously rotate while obtaining slices and does not have to start and stop between each slice. This allows visualization of entire anatomic regions such as the lungs,”(Lewis et al.,599).
    • Testing is quick and accurate, within 20 seconds.
    • This type of visualization is helpful to identify if there is an emboli in either lung.
    • Risks: exposure to radiation, allergic reaction to contrast medium
  • Ventilation and Perfusion Lung scan
    Most commonly used to test for PE
    Purpose: “test is used to identify areas of the lung not receiving ariflow or blood flow. Ventilation without perfusion suggests the probability of a pulmonary embolus,” (Lewis et al., p. 528)
    Two parts to the test:
    1. Perfusion scan: Radioisotope IV injection. Scans to detect anything in the pulmonary circulation
    2. Ventilation scan: Inhale radioactive gas (xenon). This displays how the gas within the lungs distributes.
    (Lewis et al., p. 599).
    • “In the first part of the test, you inhale a small amount of radiopharmaceutical while a camera that’s able to detect radioactive substances takes pictures of the movement of air in your lungs. A small amount of a different radiopharmaceutical is then injected into a vein in your arm, and pictures are taken of blood flow in the blood vessels of your lungs,” (Mayoclinic.com, 2007)
    • Testing: < 1hour
  • Type of test: Radiography
    Purpose: Used to confirm pulmonary embolism diagnosis.
    How it’s Done: Radio contrast is injected into the pulmonary artery or it’s branches. This is an invasive procedure. The patient is supine and a catheter is inserted via the antecubital or femoral vein to the left or the right of the pulmonary artery.
    Normal Findings: Pulmonary vessels fill symmetrically and quickly with no defects or obstruction.
    Risks: allergy to the contrast medium
    Dysrythmias
    Infection of the venous site
    Pulmonary Angiography
  • Capnogram
    Type of test: Spectrometry
    Purpose: monitoring of exhaled CO2 levels. Decreased CO2 levels can be indicative of a pulmonary embolism.
    How it’s Done: The exhaled CO2 is measured with a gas analyzer. The analyzer is usually attached to the exhalation tube on a ventilator.
    Normal Findings: 35-45mm Hg
    Risks: none
  • Type of Test: Blood
    Purpose: D-dimer helps determine the presence of a clot when there is a diagnosis of deep vein thrombosis, DIC, or an acute M.I.
    How it’s Done: Venipuncture
    Normal Findings: D-dimers <0.5 mcg/mL
    Risks: none
    D-Dimer and Fibrin Degradation Products
  • Cardiac markers
    Type of test: Serum
    Purpose: To determine if Creatine Kinase (CK) levels are elevated. Elevated CK can indicate a pulmonary embolism.
    How its Done: Blood is drawn by venipuncture at the bedside
    Normal findings:
    Adult male: 38-174 units
    Adult female: 26-140 units
    Risks: none
  • Venous Ultrasound
    • “A noninvasive “sonar” test known as a duplex venous ultrasonography, uses high- frequency sound waves to check for blood clots in your thigh veins,” (Mayoclinic.com, 2007).
    • A transducer is used to transmit any sound waves found and provides an image on a computer screen.
    • Test is fast and pain-free.
    • (Mayoclinic.com, 2007)
  • Type of Test: Blood
    Purpose: Elevated levels of Serum phosphorus can indicate can indicate pulmonary embolism.
    How It’s Done: Venipuncture
    Normal Findings: Adult: 2.5-4.5mg/dL
    Risks: none
    Phosphorous Serum
  • Arterial Blood Gas (ABG)
    Type of Test: Arterial Blood
    Purpose: Shows whether a patient is experiencing Respiratory alkalosis, which can be indicative a pulmonary embolism.
    How it’s Done: Arterial blood sample is obtained via an arterial puncture or a arterial line.
    Normal Findings:
    pH: 7.35-7.45 pCO2: 35-45mm Hg
    HCO3: 21-28mEq pO2: 80-100mm Hg
    SaO2: adult >95% Base excess/deficit: +2
    Risks: none
  • These tests are not considered diagnostic tests for a pulmonary embolism but help in the diagnostic process:
    Chest X-ray
    ECG monitoring
    CBC count with WBC differential
    History and Physical examination
    Other Tests
  • Impaired gas exchange R/T altered oxygen supply S/T ventilation perfusion mismatch.
    Acute Pain R/T inflammatory process caused by thrombus formation.
    Risk for injury R/T hypercoagulable state.
    Ineffective protection R/T prolonged bleeding S/T anticoagulation therapy.
    Anxiety R/T pain and intrusive diagnostic and surgical tests and procedures.
    Nursing Diagnosis for Pulmonary Embolism
  • Nursing interventions for preventing PE:
    • Frequent ambulation
    • Pneumatic Leg Compression Devices
    • PT consult for immobile patients
    • Pharmacologic interventions as per DOs
    • Proper IV set up
    • Patient education
  • Risk level assessment
    Weight Loss
    Exercise
    Smoking cessation
    Medication adherence
    Long Term Prevention
  • Long airplane rides
    Occupational hazards
    Pregnancies
    Oral Contraceptives and Hormone Replacement Therapy
    Other risk factors
  • Questions for Discussion
  • How does a Pulmonary Embolus cause Hypoxemia?
    Hypoxemia is a deficient oxygenation of the blood. A pulmonary embolism is a sudden blockage in a lung artery, most often caused by a traveling blood clot from a vein in the leg. These clots are formed via the condition of deep vein thrombosis.
  • A pulmonary embolism brings about lung tissue damage, hypoxia and other organ impairment as a result of your blood’s hypoxic state. Death can ensue.
    Other sources of embolism include Air embolism, Fat embolism, Amniotic fluid embolism, Septic embolism, Foreign body embolism and Tumor embolism.
  • Larger emboli can cause a reflex increase in ventilation (tachypnea), hypoxemia from ventilation/perfusion (V/Q) mismatch and shunting, atelectasis from alveolar hypocapnia and abnormalities in surfactant, and an increase in pulmonary vascular resistance caused by mechanical obstruction and vasoconstriction.
  • What are the signs and symptoms of a pulmonary embolism?
    Sudden onset of dyspnea or tachypnea
    Tachycardia
    Sharp chest pain
    Restlessness and anxiety
    Nonproductive cough or hemoptysis
    Palpitations
    Nausea
    Syncope
    Mild to moderate hypoexmia with a low PaCO2
  • What are the four major types of pulmonary emboli?
    Fat Emboli
    Air Emboli
    Amniotic Fluid Emboli
    Thrombus (Clot Emboli)
  • Long term immobility
    Oral contraceptive use
    Estrogen therapy
    Smoking
    Hypercoagulability
    Obesity
    Surgery
    Heart failure
    Chronic Atrial fibrillation
    Autoimmune hemolytic anemia (sickle cell)
    Long bone fractures
    Advanced age
    Major Risk Factors for PE
  • Are PEs usually single or multiple? What areas of the lung are most likely to be affected?
  • In most cases there are multiple emboli (Corrêa, i Cavalcanti, & Amaral Baruzzi, 2007).
    Are Pulmonary embolisms usually single or multiple?
  • The presentation of patients with PE can be categorized into 4 classes based on the acuity and severity of pulmonary arterial occlusion. (Sharma, 2006)
    Massive pulmonary embolism
    Acute pulmonary infarction
    Acute embolism without infarction:
    Multiple pulmonary emboli
    THE KEY POINT – THE BIGGER THE CLOT / OCCLUSION – THE WORSE THE SEVERITY
  • There is a predominant involvement of the lower lobes because they have a higher blood flow than the other lobes. (Lewis, SL., Heitkemper, MM., 2007)
    What areas of the lung are most likely to be affected?
  • What diagnostic tests can be used to determine the presence of a PE?
    YOUR TURN TO ANSWER
    HANDS PLEASE 
  • Ms. James pulmonary embolus was caused from a venous thromboembolism. What therapeutic modalities are used in the management of a pulmonary embolus caused from venous thromboembolism? e.g. Anticoagulation/clotting levels/antidotes Thrombolytic enzymes Inferior Vena Cava interruption Embolectomy
  • Objectives of Treatment:When diagnosis of PE has been made
    (Lewis, Heitkemper, Dirksen, O’Brien, & Bucher, 599)
    Prevent further growth or multiplication of thrombi in the lower extremities
    Prevent embolization from the upper or lower extremities to the pulmonary vascular system
    Provide cardiopulmonary support if indicated
  • Therapeutic Measures
    Anticoagulant drugs are given to prevent existing blood clots from enlarging and additional clots from forming.
    Thrombolytic drugs break up and dissolve blood clots.
    Other Methods:
    Oxygen is given if blood oxygen levels are low.
    Analgesics are given to relieve pain.
    If blood pressure is low, intravenous fluids are given and sometimes drugs that increase blood pressure are given.
    Mechanical ventilation (a breathing tube) may be needed if respiratory failure develops.
  • Drugs in Current Use
    • Anticoagulant: Parental: Heparin, Low Molecular Weight Heparin (LMWH)
    • Anticoagulant: Oral: Warfarin
    • Thrombolytics: Streptokinase, Alteplase (tPA)
  • Anticoagulants
    Heparin is given intravenously to achieve a rapid effect, and doctors carefully regulate the dose. Doctors strive to achieve a full anticoagulant effect (targeted to an INR of 2.0 to 2.5 times normal) within the first 24 hours of treatment.
    Low-molecular-weight heparin is probably as effective as traditional heparin and does not require the blood test monitoring that is commonly recommended for conventional heparin.
    Warfarin , which also inhibits clotting but takes longer to start working, is given next. Because warfarin is taken by mouth, it can be used long-term.
    Heparin and warfarin are given together for 5 to 7 days, until blood tests show that the warfarin is effectively preventing clotting. Then, the heparin is discontinued.
  • Anticoagulants: Heparin and Warfarin
    • Although both drugs decrease fibrin formation, they do so by different mechanisms:
    • Heparin inactivates thrombin and factor Xa, whereas warfarin inhibits synthesis of clotting factors.
    • Effects of heparin begin and fade rapidly, whereas effects of warfarin begin slowly but then persist for several days.
    • Different tests are used to monitor therapy:
    • PT is used to monitor warfarin: Normal range for the PT is between 10 and 13 sec.
    • aPTT is used to monitor heparin: Normal range for aPTT is between 28 to 34 sec.
    • Vitamin K is given to counteract warfarin whereas protamine is given to counteract heparin.
  • Low-Molecular Weight Heparin
    • LMWHs are simply heparin preparations composed of molecules that are shorter than those found in unfractionated heparin.
    • LMWHs are associated with a much lower incidence of heparin-inducedthrombocytopenia than heparin and a lower incidence of osteoporosis.
    • Administration of LMWHs is in a fixed dose by subcutaneous injection and don’t require aPTT monitoring, as opposed to heparin.
    • As a result, LMW heparins can be used at home, an advance that would reduce cost and improve patient convenience.
  • Duration of Therapy
    How long anticoagulants are given depends on the person's situation.
    If pulmonary embolism is caused by a temporary risk factor, such as surgery, treatment is given for 2 to 3 months.
    If the cause is some longer-term problem, such as prolonged bed rest, treatment usually is given for 3 to 6 months, but sometimes it must continue indefinitely.
    For example, people who have recurrent pulmonary embolism, often because of a hereditary clotting disorder, usually take anticoagulants indefinitely.
    While taking warfarin, people periodically have to have a blood test to determine if the dose needs to be adjusted.
  • Diet and Drug Interactions
    Changes in diet and use of other drugs may affect the degree of warfarin's anticoagulant effects. If excessive anticoagulation occurs, severe bleeding in a number of body organs can develop.
    Because many drugs can interact with warfarin, people who take anticoagulants should be sure to check with their doctor before taking any other drugs, including drugs that can be obtained without a prescription (over-the-counter drugs)
    Such as acetaminophen or aspirin, herbal preparations, and dietary supplements.
    Foods that are high in vitamin K (which affects blood clotting)
    Such as broccoli, spinach, kale, and other leafy green vegetables, liver, grapefruit and grapefruit juice, and green tea, may also need to be avoided.
  • Thrombolytic Drugs
    • Thrombolytic drugs such as streptokinase or tissue plasminogen activator (TPA) break up and dissolve blood clots.
    • Thrombolysis is moreexpensive than anticoagulant therapy and is associated witha higher risk of bleeding, so its use should be restricted topatients who are likely to benefit from it.
    • They can be used for people who appear to be in danger of dying of pulmonary embolism.
    • However, except in the most dire situations, these drugs cannot be given to people who have had surgery in the preceding 2 weeks, are pregnant, have had a recent stroke, or tend to bleed excessively.
  • Thrombolytics
    • The fibrinolytic enzymes streptokinase, and Alteplase (tPA) accelerate therate of dissolution of thrombi and emboli by converting plasminogen to plasmin, an enzyme that degrades the fibrin matrix of thrombi.
  • Depending on the severity of the pulmonary embolism and the patient’s ABG results, supplemental oxygen may be needed by mask or nasal cannula.
    In some cases, patients may even need endotracheal intubation and mechanical ventilation
    Perform nursing interventions to prevent or treat atelectasis and maintain perfusion
    Respiratory Measures
  • Inferior vena cava interruption
    • Filters – most commonly used for procedure
    • Ligation and external clips – rarely used
    Pulmonary embolectomy
    • Surgery is performed to remove clot
    • Another type of embolectomy involves an introduced catheter to remove the clot
    Surgical Therapy
  • Prior to the surgery, a pulmonary angiography should be performed to visualize or rule out an embolus
    A filter is placed into the inferior vena cava typically beneath the renal vein under fluoroscopic guidance
    The filter will prevent large clots from travelling to the lungs by mechanically blocking their migration
    There are several types of filters and they fall into two categories: Permanent or Retrievable
    Inferior Vena Cava Filter
  • Indications -
    A patient that has a contraindication to anticoagulants, complications of anticoagulation therapy, or failure to anticoagulant therapy.
    Prophylactic measure for patients with complications where a small PE would have severe consequences
    Patient undergoing pulmonary embolectomy
    Contraindications –
    A thrombus in the inferior vena cava blocking possible placement
    Uncorrectable, severe coagulapathy
    Bacteremia - the presence of bacteria in the blood
    Inferior Vena Cava Filter
  • Benefits –
    Short-term reduction of occurrence of PE in patients with DVT with a likely sequelae of PE
    High rate of long term patency
    Complications – (Retrieved from the British Journal of Haematology)
    Immediate - Misplacement (1-3%),
    Early - Insertion site thrombosis (8.5%), and Infection
    Late - Recurrent DVT (21%), IVC thrombosis (2-10%), Post-thrombotic syndrome (15-40%), and IVC penetration (0.3%)
    Inferior Vena Cava Filter
  • Panel A showing a postoperative picture of the IVC filter encased in blood clot.
    Panel B showing an intraoperative picture of the IVC filter in the right pulmonary artery.
    Abouzgheib W. et al.; Eur J Cardiothorac Surg 2008;33:507
    Copyright ©2008 European Association for Cardio-Thoracic Surgery. Published by Elsevier. All rights reserved.
  • A rare procedure where a clot is surgically removed from the pulmonary system
    Preoperative angiography must be done to find and confirm the pulmonary embolism
    An emergent embolectomy may be indicated for a patient with a severe obstruction who did not respond to the usual therapy
    IVC filter is placed after embolectomy
    Lewis et al. mentions the mortality rate of the procedure is 50%.
    Pulmonary Embolectomy
  • Respiratory measures -
    When atelectasis was found on the chest x-ray, she was placed on 4L/min of oxygen via nasal cannula
    The next day, Ms. James has an oxygen saturation of 81%, her ABG results show that her PaO2 is 45, and she is showing sings of tachycardia, diaphoresis, and cyanosis. Because she has a suspected PE, she is intubated and placed on a volume ventilator.
    Nursing actions are performed by suctioning the blood-tinged secretions from her endotracheal tube.
    Ms. James’ treatment
  • Ms. James’ Treatment
    Surgical Intervention
    Pulmonary angiogram is performed revealing an emboli in the left upper lobe lingular and right main pulmonary arteries
    Bilateral iliac vein Greenfield filters are placed under fluoroscopy.
    • Bilateral – inserted on both left and right side
    • Fluoroscopy – use of x-rays to guide insertion
    • Greenfield filters – Permanent, stainless steel
    • Iliac vein:
  • What nursing measures can decrease the chance of a PE?
    NURSES – WHAT DO YOU THINK ?????
  • References
    Abouzgheib, W. Z. (2007, December 21). Images in cardio-thoracic surgery: Migration of an inferior vena cava filter to the pulmonary artery. Retrieved February 7, 2009, from European Journal of Cardio-Thoracic surgery: http://ejcts.ctsnetjournals.org/cgi/content/full/33/3/507?eaf
    Baglin, T. B. (2006). Guidelines on use of vena cava filters. Retrieved February 6, 2009, from Journal Compilation: http://www.bcshguidelines.com/pdf/bjh_6226.pdf
    Corrêa, T. D., i Cavalcanti, A. B., & Amaral Baruzzi, A. C. (2007). Pulmonary embolism: epidemiology and diagnosis. Part 1. Einstein , 288-293.
    Emde, K., & Rush, C. (2001). Suspecting Pulmonay Embolism. The American Journal of Nursing , 19-24.
    Geerts, W. O. (2007, February). Inferior Vena Cava Filters. Retrieved February 7, 2009, from The Thrombosis Interest Group Of Canada: http://www.tigc.org/eguidelines/venacava04.htm
  • Hennessey, B., FitzGerald, A., & Graham, D. (1993). Venous Air Embolism: Keeping Your Patient out of Danger. The American Journal of Nursing , 54-56.
    Hirsch, J. MD; Hoak, J. MD. (1999). Management of Deep Vein Thrombosis and Pulmonary Embolism Retrieved January 28, 2009, from American Heart Association Journals: http://circ.ahajournals.org/cgi/content/full/93/12/2212
    Lehne, R. A. (2009). Pharmacology for Nursing Care 6th Edition. St. Louis: Elsevier.
    Lewis, SL., Heitkemper, MM., Dirksen, SR., O’brien, PG., Bucher, L. (2007). Medical- Surgical  Nursing Volume 1, 2: Assessment and Management of clinical problems (7th Ed) St.  Louis, Mosby Elsevier
  • Mayoclinic, S. (2007, September 28). Pulmonary Embolism Symptoms - MayoClinic.com. Retrieved February 6, 2009, from MayoClinic.com: http://www.mayoclinic.com/health/pulmonary-embolism/DS00429/DSECTION=symptoms
    Mayoclinic, S. (2007, September 28). Pulmonary Embolism Diagnosis - Mayoclinic.com. Retrieved February 3, 2009, from : http://mayoclinic.com/health/pulmonary-embolism/DS00429/DSECTION=tests%2Dand%2Ddiagnosis.
    McMorrow, L. M. (2005). Nursing Guide to Laboratory and Diagnostic Tests. St. Louis: Elsevier Saunders.
    Moore, L. E. (n.d.). Retrieved February 5, 2009, from eMedicine: http://emedicine.medscape.com/article/253068-overview
    Murray, S., & McKinney, E. (2006). Foundations of Maternal-Newborn Nursing, 4th Edition. In S. Murray, & E. McKinney. Elsevier Inc.
    Mosby’s dictionary of medicine, nursing, and health professions, 7th edition. St. Louis, Missouri: Mosby Elsevier.
  • Newman, J. H. MD. (2007, August). Pulmonary Embolism. Retrieved February 9, 2009, from www.merck.com: http://www.merck.com/mmhe/sec04/ch046/ch046a.html
     
    Pulmonary Embolism Symptoms ~ APS Foundation of America, Inc. (2005, December 4). Retrieved February 6, 2009, from APS Foundation of America, Inc: http://www.apsfa.org/pesymptoms.htm
    Sharma, S. (2006, June 2). Pulmonary Embolism. Retrieved February 8, 2009, from emedicine: http://emedicine.medscape.com/article/300901-overview
    Stanton, J. R. (1955). Venous Thrombosis and Pulmonary Embolism. The American Journal of Nursing , 709-711.
    Swearingen, P.L. (2008). All-in-one care planning resource: medical-surgical, pediatric, maternity, and psychiatric nursing care plans. (2nd ed.). St. Louis, Missouri: Mosby Elsevier.
    Wittenberg, A.G. (2006). Venous air embolism. Retrieved February 6, 2008, from eMedicine WebMD on the World Wide Web: http://emedicine.medscape.com/article/761367-overview